What is overindulgence?

Overindulgence is defined as excess, overeating, lack of restraint or to binge.

The liver plays an important role in the digestive process, as it assists with the digestion of fatty foods as well as the breakdown of alcohol. Excessive intake of alcohol and fatty foods may overtax the liver, causing symptoms of overindulgence, such as:

• Indigestion
• Feeling bloated
• Feeling tired
• Abdominal tenderness and discomfort
• Nausea
• Vomiting in extreme cases.

Alcohol

People differ in their tolerance level for alcohol. The dietary suggestion to the public is 1-2 small glasses of wine or 1-2 cans of beer per day – but even this is above the recommended dose for drivers these days.

Alcohol units

Always be aware of the number of alcohol units consumed. A large glass of wine, for instance, contains around 3 units. According to South Africans Against Drunk Driving (SADD) one alcohol unit will result in 0.02g in blood or 0.10 mg in breath. Three units of alcohol will translate into a blood alcohol level of 0.06 g and 0.3 mg in breath calculated for an adult male of about 68 kg who has eaten a meal. The legal limit is <0.05mg in blood and <0.24 mg in breath.

It takes 1 hour or more to get rid of 1 alcohol unit. A few examples:

Sorghum beer             1.5 units

Spirit cooler                1.5 – 1.9 units

Beer (can)                   1.5 – 1.7 units

Cider (can)                  2 units

Red wine (75 ml)        1 unit

White wine (90ml)      1 unit

Tequila (25 ml)           1 unit

Spirits (25 ml)             1 unit

The NHS (?? National Health System) recommends:

• Men should not regularly drink more than 3-4 units of alcohol a day
• Women should not regularly drink more than 2-3 units a day.

Regularly means drinking this amount every day or most days of the week.

Effects of alcohol

Alcohol is broken down by the liver, raising the liver enzymes and potentially leading to hepatitis. Most of the alcohol consumed must be metabolised in the liver; this process requires a lot of work and takes precedence over many other necessary functions. Therefore fat metabolism is decreased and fatty build-up can occur in the liver. Alcohol does not convert to glucose or glycogen, but to fat, which may later lead to obesity with high alcohol use.

Vitamin and mineral interactions show that alcohol diminishes the stores of many of the B vitamins, including vitamin B2 and B6, vitamin A, vitamin E, beta-carotene and magnesium. Alcohol consumption impairs the absorption of the enzymes in the liver that activates these vitamins, therefore, it is essential to supplement.

Hangovers

Hangovers represent the very unpleasant side-effects of drinking alcohol. Alcohol dehydrates the cells, removes fluid from the blood, swells the cranial arteries and irritates the gastrointestinal tract.

Many of the side-effects are caused from dehydration and can be remedied by taking water while drinking and also large amounts before going to sleep. Raising blood sugar levels with a snack of fruit before bed will also help.

The common hangover includes some or all of the following:

• Headache
• Poor sense of overall well-being
• Sensitivity to light and sound
• Diarrhoea
• Loss of appetite
• Trembling
• Nausea
• Fatigue
• Increased heart rate and blood pressure
• Dehydration (dry mouth, extreme thirst, dry eyes)
• Inability to concentrate
• Anxiety
• Difficulty sleeping
• Weakness.

When alcohol is consumed, it enters the bloodstream and causes the pituitary gland in the brain to block the creation of vasopressin (the anti-diuretic hormone). Therefore, the kidneys send water directly to the bladder instead of reabsorbing it into the body. According to studies, drinking about 250 ml of an alcoholic beverage causes the body to expel 800 to 1000 ml of water; four times as much liquid lost as gained.

The morning after heavy drinking, the body sends a desperate message to replenish its water supply — usually manifested in the form of an extremely dry mouth. Headaches result from dehydration because the body’s organs try to make up for their own water loss by taking water from the brain.

The frequent urination also expels salts and potassium that are necessary for proper nerve and muscle function. When sodium and potassium levels get too low, headaches, fatigue and nausea can result.

Alcohol also breaks down the body’s store of glycogen in the liver, turning the chemical into glucose and sending it out of the body in the urine. Lack of this key energy source is partly responsible for the weakness, fatigue and lack of coordination the next morning.

Because alcohol is absorbed directly through the stomach, the cells that line the organ become irritated. Alcohol also promotes secretion of hydrochloric acid in the stomach causing heartburn and eventually vomiting.

Treatment

Painkillers

Certain painkillers are more effective at combating a hangover than others. It will relieve the headache in the short-term but may have some long-term side-effects.

Combination painkillers can be helpful for a headache because it combines paracetamol or aspirin for the pain and caffeine that reduces the size of the pounding blood vessels. However, prolonged combination of alcohol and paracetamol has been shown to cause liver damage. It should also be taken into consideration that caffeine is a diuretic and can worsen the symptoms of dehydration.

Aspirin belongs to the class of anti-inflammatory drugs known as prostaglandin inhibitors. High levels of prostaglandins have been associated with increased hangover severity. In one study, participants who took a prostaglandin inhibitor before bed reported less of a headache and less nausea and thirst than those who had drunk the same amount of alcohol but did not take the prostaglandin inhibitor before bed. Aspirin may aggravate the already irritated mucosa of the stomach.

Over-the-counter remedies

Several OTC products are available to treat a variety of symptoms of a hangover.

Alcohol irritates the digestive system. This can lead to nausea and high acidity levels in the stomach the next day. If nausea is the problem, eating something bland like dry toast should help or possibly take domperidone (Motilium®) to settle the stomach. Avoid cereal because the fatty content of milk can add to queasiness. Popular remedies like Eno® and Rennie® can ease acidity.

The liver can be protected by lipotropic agents containing B-complex vitamins (Essentiale®) while Gurosan® acts as a tonic against fatigue. The KGB® pill is reported to effectively protect the body from alcohol damage.

Rehydration sachets, usually used for treating diarrhoea, can speed recovery from a hangover. This is because they contain small amounts of electrolytes that replace lost fluids quicker than water alone. Mix one sachet with water and drink before you go to bed, then do the same the morning after. Isotonic sports drinks also contain these salts.

Berocca® tablets may help to replace nutrients lost after a drinking session. The effervescent tablets contain vitamins B, C, calcium and magnesium.

Natural treatments

Natural and holistic treatments such as herbal and homeopathic remedies have proven to be highly effective in providing relief for symptoms associated with overindulgence or an alcohol hangover.

Powerful herbs such as Silybum marianus (milk thistle), Althaea officinalis (marshmallow) and Ulmus fulva (slippery elm) support the liver and promote balance and equilibrium in the body during times of excess and overindulgence.

Homeopathic remedies help the body restore balance at a cellular level. Carefully selected ingredients such as Lupulus humulus, Lobelia inflata and Nux vomica is the homeopathic hangover remedy to reduce the side-effects of a dry mouth, dry eyes, headache and nausea.

Home remedies

A number of home remedies exist and have been passed on from generation to generation – but not all of them are effective.

Hangover sufferers usually feel a bit shaky, due to a lack of sugar in the blood. A breakfast of toast with honey is best to combat symptoms, according to the Royal Society of Chemistry. This provides the body with sodium, potassium and fructose – all of which are lost after a night of boozing. Add a banana to further boost potassium and fructose levels.

A glass of pure fruit juice or a smoothie will also lift the blood sugar levels and avoid the quick drop that high sugar fixes like pastries will bring. Fruit is packed with vitamin C which helps the liver to process alcohol.

The drop in blood sugar can also lead to hunger the next day. Be careful not to have to digest  loads of fat as this will put extra strain on the already stressed digestive system. Try scrambled eggs on toast with baked beans. The beans and bread will steady blood sugar levels, while eggs contain cysteine that is thought to mop up the toxins that build up in the liver.

Prevention

Researchers have found the following general regimens minimise the symptoms of a hangover.

Before drinking

• Eat a full meal – A full stomach slows down the absorption of alcohol, giving the body more time to process the toxins. Fatty foods and carbohydrates increase this effect.
• Start with a glass of water – This ensures the body is hydrated before the diuretic effect takes hold.
• Take multivitamins – This better prepares the body for the depletion of vitamins caused by frequent urination.

While drinking

• Drink in moderation – Ideally, drinkers should limit themselves to one drink per hour because the body takes about an hour to process a single drink.
• Drink a glass of water after every alcoholic beverage – In addition to helping keep a drinker hydrated, this will give the body more time to process the alcohol, dilute the toxins and reduce irritation of the stomach. Sports drinks will replenish electrolytes, salts and sugars lost in the urine.
• Avoid mixing drinks – Drinkers generally fare better when they stick with one drink. Each new type of alcohol a drinker puts into his or her system makes the body work that much harder and puts that many more toxins in the body, leading to a more severe hangover.
• Beer has the lowest percentage of alcohol (4 to 6 percent), but is carbonated, which speeds up the absorption and can lead to toxin buildup.
• Wine has a higher percentage of alcohol (7 to 15 percent) than beer. White wine is safer than red or blush because it has fewer congeners (byproducts of fermentation). In general, the cheaper the wine, the higher the congener content and the worse the hangover.
• Liqueur has the highest alcohol content (40 to 95 percent) and therefore increases the likelihood of a hangover. Clear liquors like vodka, rum and gin are better than dark or sweet liquors like bourbon, scotch or tequila because they have fewer congeners.

After drinking

• Take two aspirin with a full glass of water before bedtime and on waking – The prostaglandin inhibitors in the aspirin can decrease hangover severity.

• Take another multivitamin – Replenishing C and B vitamins in particular can help get rid of the rest of the toxins.
• Eat breakfast – A meal that includes eggs (for the cysteine), a banana (for the potassium), and fruit juice (for the fructose) or a sports drink (for the electrolytes, sugars and salts) can get the body on the road to recovery. Keep in mind that caffeinated coffee, tea and soda will further dehydrate a drinker.

Even though one may be more tempted to overeat during the holidays, the right precautions will promote healthy digestion any time of the year when one overindulges in food and drink.

Depression is classified as a mood disorder

Mood disorders are defined by the presence of mood episodes (which can either be major depressive, manic, mixed, hypomanic mood episodes).These mood episodes represent a combination of symptoms comprising a predominant mood state.

Classification

Mood disorders are classified into the following:

• Depressive (major depressive disorder, dysthymia disorder)

• Bipolar (bipolar I/II disorder, cyclothymia disorder)

• Mood disorder secondary to general medical condition, substance abuse or medications.

DEPRESSIVE DISORDERS

Major Depressive Disorder (MDD) is diagnosed where there is a positive history of

one or more Major Depressive Episodes.

Epidemiology

The prevalence of MDD differs between males and females. The lifetime risk for a male is 2-4% compared to a female having a 5-9% lifetime risk. MDD has a mean age of onset of 30 years, compared to bipolar disorder which presents earlier, typically in adolescence.

Etiology of mood disorders are classified into different categories

Biological factors

• Biogenic amines, better known as neurotransmitters are mostly implicated in the etiology of mood disorders. Research has shown that noradrenaline and serotonin play a major role.
• Neuro-endocrine regulation with abnormalities in the limbic-hypothalamus-pituitary and adrenal axis together with abnormal sleeping patterns has been proven to play a role in the etiology of mood disorders.

Genetic factors

• Major depressive disorders and bipolar mood disorders run in families.

Psychosocial factors

• Life events and environmental stressors often precede the first episode of mood disorders e.g. the loss of a parent.
• Premorbid personality disorders such as obsessive-compulsive disorders, dependant personalities or histrionic personality traits.

 Risk factors

The following factors have been identified as risk factors for the development of MDD:

• Sex: female

• Age: onset in 25-50 age group

• Positive family history of depression and alcohol abuse

• Childhood experiences such as loss of a parent before 11 years old, negative home environment with abuse and neglect.

• Personality traits such as insecure, dependent, obsessional personality disorders

• Recent stressors

• Mothers who just delivered are at risk for developing MDD due to hormonal influences.

• Lack of intimate, confiding relationships (social isolation) 

Major depressive disorder is diagnosed when there is a positive history of one or more Major Depressive Episodes (MDE), in the absence of a previous manic, hypomanic, or mixed episode.

Major Depressive Episode can be diagnosed when:

A. at least five of the following symptoms have been present during the same two week period and represent a change from previous function, one of which must be either depressed mood or loss of interest:

• Depressed mood for most of the day, nearly every day, as indicated by either subjective report or observation made by others.
• Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day as indicated by either subjective account or observation of others.
• Significant weight loss when not dieting or weight gain, resulting in a change of more than five percent body weight in a month.
• Insomnia or hypersomnia nearly everyday.
• Psychomotor agitation or retardation, observed by others, or merely subjective feelings of restlessness or being slowed down.
• Fatigue or loss of energy nearly every day.
• Feelings of worthlessness or excessive or inappropriate guilt.
• Diminished ability to think or concentrate, or indecisiveness.
• Recurrent thoughts of death, recurrent suicidal ideation without a specific plan or a suicide attempt with a specific plan to commit suicide.

B. symptoms do not meet criteria for mixed episode as expected in bipolar mood type 2 disorder

C. symptoms cause significant social or occupational impairment/distress.

D. symptoms are not better explained due to physiological effects of a substance or due to a general medical condition.

E. symptoms not better accounted for by bereavement (a constellation of depressive symptoms meeting criteria for a MDE appearing within two months of the death of a close relative)

Treatment

The aim of treatment is complete remission, to treat the acute episode and prevent future episodes by continuing medication at full dose for 6-12months after remission.

This can be achieved by the following interventions:

• Biological: antidepressants, lithium, electroconvulsive therapy (ECT)

• Psychological: psychodynamic, cognitive, behavioural, family, and group therapy

• Social: vocational rehabilitation and social skills training

Antidepressants are classified into different classes

• SSRI (selective serotonin re-uptake inhibitors)
• TCA (tricyclic antidepressants)
• SNRI (serotonin and noradrenaline re-uptake inhibitors)
• NARI(noradrenaline re-uptake inhibitors)
• MAOI (monoamine oxidase inhibitors)

SSRIs are mostly used for the treatment of depression. They are all taken orally, are safe in overdose, better tolerated, have acceptability of long term use with a better side effect profile. Some of the most common side effects of the SSRIs include:

• Agitation, akathisia(restlessness), anxiety, panic attacks, insomnia, nausea, diarrhea,headache and sexual dysfunction

Available SSRIs include- fluoxetine,paroxetine, citalopram, escitalopram and sertraline.

Prognosis

The risk of recurrence is significant, with 50% relapse after the first episode, 75% after the second episode and 90% after the third episode.

Conclusion

Depression can be treated successfully with recovery being the rule, not the exception!

Gout is often referred to as the disease of kings. This “rich man’s” disease has been documented by the Egyptians (2600 BC) as arthritis of the big toe!  The name gout is derived from the Latin word “gutta” which means a drop of liquid! Never mind history, but gouty patients spend nights in torture.

What gout is: Gout is a disease characterised by increased levels of uric acid in body fluids. It is an excruciatingly painful arthritic joint inflammation of sudden onset. It caused by the formation and deposition on urate crystals in the affected joint.

Purines are part of all human tissue and found in many foods. Purines produce uric acid and uric acid produces urate crystals. Uric acid has two chemical forms (tautomeres) in which it exists. The one is stable and the other unstable. The unstable form can form urate crystals which are nearly insoluble in water and deposit themselves in the joints to cause gout.

Causes: The uric acid excess (hyperuricemia) can be caused by the following:

ü  Production of uric acid: An over-production of uric acid by the body as part of the normal excretion processes. Over production contributes to about 10% of all incidents

ü  Excretion of uric acid: An under-excretion of uric acid by the kidneys contributes to about 90% of all gout attacks

ü  Dietary factors. Diets high in purine-containing foods can contribute to the development of gout

ü  Genetic pre-disposition: Lesch-Nyhan Syndrome is a genetic disease caused by an enzyme deficiency.

ü  Medication: Stopping or starting certain anti-gout medication can precipitate an acute gout attack. Certain diuretics may also cause gout.

ü  Aspirin: Aspirin should no longer be recommended as it can cause an acute gout attack at low doses and patients may experience side-effects at higher doses

ü  Family history: Gout tends to stay in families!

Gout is confirmed by the microscopic visualization of the urate crystals in the joint fluid. 

Who gets gout? Gout frequently occurs in combination with other medical conditions. The following may increase the changes of experiencing gout attacks:

• Males experience gout more frequently than females
• Obesity and persons with BMI (body mass index) greater or equal to 35
• Abdominal obesity (apple shape) where body fat is stored around the middle (abdomen and chest). This condition is linked with health problems such as coronary heart disease, diabetes, stroke, high blood pressure and gall bladder problems.
• Insulin resistance
• High cholesterol levels 

Signs and Symptoms: Gout can present in different joints, but the joint of the big toe is most often affected and account for 50% of all gout attacks. Other joints, such as the heels, knee, wrist and fingers may also be affected. The following are characteristic of gout:

ü  Recurrent: It has a recurrent nature and will return again and again

ü  Intense pain: The acute attack usually begins between two and four in the morning. This is due to the lower body temperature during the night

ü  Inflammation has the following components

• The affected joint is red
• Swelling of the joint
• Hot:
• The affected joint is very sensitive to any touch

ü  Fatigue and fever

ü  Tophi: Long-standing increased uric acid levels may result in hard, painless deposits of uric acid crystals. These deposits are known as Tophi.

Treatments and Prevention: The aim of gout treatment is to settle the symptoms of the acute attack. The following are used to assist with the treatment of gout:

ü  Cold compress: The application of cold compress several times during the day may decrease the inflammation and pain.

ü  Colchicine: Aspen Colchicine is a Schedule 3 (S3) medication, but it is S2 when indicated for the relief of acute gout attack in cases of emergency. This can be recommended by a pharmacist’s assistant under supervision of a pharmacist. The patient should take 2 tablets immediately and followed by 1 tablet every two hours until relief is obtained or diarree occur. The maximum quantity of tablets per attack is 6 and the treatment should not be repeated within 3 days.

ü  NSAID: Non-steroid anti-inflammatory drugs are usually the first line treatment for gout. Improvement may be expected within 4 hours, and treatment is recommended for one to two weeks. These drugs work by inhibiting the formation of prostaglandin production. Prostaglandins are the chemicals responsible for the development of inflammation. One of the following NSAIDS can be recommended:

• Ibuprofen: Nurofen contains 200mg ibuprofen in a sugar-coated dosage form. It can be recommended to fight inflammation. Advil LiquiGelS caplets also contain 200mg but in a gel-capsule. Their onset of action is faster. Patients should not exceed 6x200mg tablets per 24hour period.

• Diclofenac: Diclofenac contains analgesic (pain-relieving), anti-inflammatory and anti-pyretic (anti-fever) properties. Two Voltaren Actigo(S2) tablets immediately followed by one every four hours can be recommended to those in acute gout and other inflammatory conditions. The patient should not exceed the 6 tablet per day maximum allowed.
• Aspen Dicloflam is a schedule 3 medication, but when intended for the treatment of inflammation and pain, it is schedule 2 (S2).  Bear in mind that one cannot give more than 15 tablets as this is the maximum that is allowed over the approved 5-day period.

• Naproxen: Aleve contains naproxen sodium. Two tablets immediately and then one twelve hourly can be recommended. It is important not to exceed the daily dose of 3 caplets per 24hour period. Naproxen has received FDA approval for gout.

It is important that NSAIDS should be taken after meals and it should not be recommended to patients with ulcers.

ü  Urinary alkalinisation: The pH of urine can be increased by the administration of bicarbonate and citrate salts. These agents may be helpful to increase the solubility of high concentrations of uric acid in the urine. The increase in excretion of uric acid may contribute to reduce potential stone formation. Citro-Soda and Citro-Soda with Cranberry extract can be recommended as urinary alkalinising agents. 

Lifestyle and prevention: Lifestyle changes can also contribute to the prevention of gout. The following is important:

• Low purine diet: Gout is not primarily caused by one’s diet and what one eats, but it is caused by the inability of the body to flush out the breakdown products (urea and uric acid). The healthier lifestyle program is not a bad thing as can also directly assist one in the prevention of several other potentially chronic diseases. The following food contain a high concentration of purine and should be taken with caution:

Dietary changes can contribute to about 12% reduction in gout attacks!

• Achieve ideal and maintain body weight:  If one is over the recommended average weight, follow a program that will see a steady (but not overdramatic) loss of weight. Take note that fasting and rapid weight loss can actually increase the occurrences of gout attacks and can be counter-productive.

• 5-HT: Solal 5-HTP Feel Good this product boosts mood, reduces anxiety and helps curb excessive appetite, especially carbohydrate craving. 5-HTP is the pre-cursor of the neurotransmitter serotonin. Ashwagandha is a herbal extract which helps improve resistance to environmental stress, thereby protecting the brain and heart from stress-damage.
• Green tea: Leanor Herbal Concentrate is a herbal formulation containing extracts of green tea, ginseng and other herbs specially formulated to help provide support for an active and healthy metabolism. Recommend 10 drops in water three times daily.

• Healthy lifestyle actions:
• Water: Increase water intake as it helps to flush the uric acid from the system. Coffee, but not tea, consumption is associated with a lower risk of gout.
• Exercise: Exercise is essential for a healthy body.
• Alcohol: Keep alcohol consumption to a minimum, avoid beer and strong spirits. If possible, avoid alcohol totally. Fructose-sweetened drinks can also precipitate attacks.
• Diary: Introduce low-fat dairy products into your diet and avoid products such as butter and cream.
• Fats: Reduce fat intake.  Choose grilled options instead of frying!
• Stop smoking: Nicorette Chews  and Patches can be recommended.

• Sleep Apnea: Breathing pauses during sleep from a few seconds to minutes. Typically, breathing starts again with a loud snort or choking sound. Gout may be secondary to sleep-apnea via the release of purines from oxygen-starved cells. The treatment of apnea can lessen the frequency of attacks!  The following can assist with reducing sleep apnea:
• Sleep on the side instead of the back. This help to keep the throat open. Special pillows are also available!
• Keep the nasal passages open at night with nasal sprays or allergy medicines, if needed. Decongestant nasal sprays can be recommended:
• Oxymetasoline: Iliadin Nasal Decongestant is a topical vasoconstrictor which acts as a decongestant on the nasopharyngeal cavity’s mucosa lining.

• Supplementation: Supplementation is essential for optimum health!
• Vitamin C: Vital Vitamin C Chewable Tablets contains 300mg vitamin C and citrus bioflavonoids in a buffered formulation. Recommend patients to chew two tablets daily.
• Multivitamin: A multivitamin daily, containing the antioxidant vitamins A, C, E, the B-complex vitamins, and trace minerals such as magnesium, calcium, zinc and selenium. Centrum and Pharmaton can be recommended with confidence!
• Omega-3 and 6 fatty acids: Cold water fish, such as salmon, is an excellent source of omega-3 fatty acid. Recommend one Vital Omega-3 Concentrate daily, to help decrease inflammation and promote general health. Clicks Omega 3 & 6 has added Evening Primrose oil and should also be recommended as part of staying healthy. It is important to remember that these fatty acids have blood-thinning effects and persons on blood thinning treatment should be referred to the pharmacist.
• Probiotic:  Probiotic supplementation is needed for maintenance of a healthy gastro-intestinal tract. Inteflora contains Saccharomyces boulardi while Probiflora Intensive9 a selection of 9 different probiotic strains contains.   Recommend one capsule daily to maintain overall
• MSM: Methylsulfonylmethane (MSM) combined with glucosamine and chondroitin (OsteoEze MSM or Arthro Guard) taken daily will take care of the joints. The nutrients will prevent further degradation of cartilage and damage caused by the uric acid crystals and have anti-inflammatory actions. 

Avoid taking extra niacin and vitamin A as both may play a role in some attacks of gout.

Conclusion: Gout is a very painful condition! Proper treatment of an acute attack and prevention more attacks are the goals.

References:  Available on request

]]> http://www.frontshop.co.za/gout-the-disease-of-kings/feed/ 0 http://www.frontshop.co.za/emergency-contraception-pharmacist-to-the-rescue/ http://www.frontshop.co.za/emergency-contraception-pharmacist-to-the-rescue/#comments Fri, 18 Nov 2011 09:46:30 +0000 Dr Karen Koch http://www.frontshop.co.za/?p=1708 Accidents happen.  Condoms break.  Women are sexually assaulted. Someone forgets to take their combined oral contraceptive pill. There are numerous reasons why a client may ask you about emergency contraception (also known as ‘the morning after pill’).

South Africa is one of the many countries around the world where Emergency Contraception is available without a script. Since public clinics have long queues and many people can’t afford to see a private doctor, the pharmacy is often the first port of call for emergency contraception.

What is emergency contraception?

Emergency contraception is treatment which can be given where a couple have had unprotected sex to prevent pregnancy. Emergency contraception should, ideally be taken within one to two days of the incident, but there are treatments which can work up to five days after unprotected sex. The main message to give your clients is that the sooner emergency contraception is taken, the better.

What emergency contraception options are there?

Assessing the situation

It can be difficult for clients to discuss the details of their problem with you. Make sure there is enough privacy to ask them for the necessary information.

1. Does my client need emergency contraception? It’s always better to err on the side of giving emergency contraception, rather than not. If your client is concerned that she’s at risk of having fallen pregnant from failed contraceptives or unprotected sex for any reason, then give her the medication.
2. Will the emergency contraception we have be effective? Emergency contraception works best if taken within 72 hours of unprotected sex. If it has been more than 72 hours since your client has had unprotected sex, or if she cannot remember the exact time interval,  rather offer her emergency contraception, but  also advise her to see her doctor or visit her clinic as soon as possible.
3. Should I discuss Sexually Transmitted Infections (STIs)? You should always advise your clients about HIV and other STIs. Ask them whether they have considered taking HIV post-exposure prophylaxis. It needs to be taken within 72 hours of unprotected sex.  There are many people in South Africa who are not aware that HIV prophylaxis is available in an emergency.  They will need to see their doctor or local clinic as soon as possible to get preventative treatment for STIs.

Some side effects to mention

1. Nausea and vomiting: Emergency contraception can cause nausea and vomiting. If your client vomits within 2 hours of taking the medication dosage, she will need to take another dose immediately. While it’s not routine practice, clients can also take an anti-emetic along with emergency contraception to prevent this.
2. Menstrual cycle abnormalities: Around 50% of women will have a period (withdrawal bleed) within seven days of taking emergency contraception. If your client has no withdrawal bleed and then has a delayed period thereafter, she should go for a pregnancy test.

Is there anyone who can’t take emergency contraception?

There is absolutely no contraindication to emergency contraception other than a known pregnancy.

Should an unaccompanied child be given an emergency contraception?

Legally any child from the age of 12 can request medical treatment without the consent of their parent or guardian. This means that you are obliged to assist. Having said this, you should of course be concerned about anyone so young seeking emergency contraception at all and especially on their own.

It’s a very difficult situation. The legal age of consent for sex in South Africa is 16. This means that it is illegal for anyone to have sex with a child under the age of 16, regardless of whether they have consented or not. Children who have been sexually assaulted may not be able to turn to their parents for help. Furthermore, if you have any grounds to suspect sexual assault in a minor you are also legally obliged to report it in terms of the Child Care Act.

• Reassure the child that you are there to assist
• Offer to call someone on behalf of the child.
• Keep the Childline telephone number handy (08000 55 555) and make sure the victim knows that it can be dialed for help any time of the day or night..

What to do if the victim cannot afford treatment?

Make sure you know where the closest local clinic is near your pharmacy. You need to be able to give immediate advice and support. The sooner your client takes emergency contraception, the more effective it is likely to be.

What should I do if I suspect a rape?

A woman who has been raped needs medical advice and support beyond that which can be provided at your pharmacy. You should of course provide her with emergency contraception, but also impart the importance of seeing a doctor immediately in order to:

• Receive crisis counseling
• Access HIV prophylaxis
• Undergo a forensic examination

When referring, don’t forget that most Netcare Hospitals provide a free-of-charge rape crisis service to the public.

Caring for your client

Women will turn to you for help in accessing emergency contraception. Your knowledge can make an enormous difference to their lives. The problem may be far bigger than just a broken condom so don’t forget to inform them about HIV post- exposure prophylaxis. Always be sensitive to the possibility of sexual assault and don’t just turn a blind eye.

Identifying an emergency

Should you call 911? People don’t always think their pain is serious enough to warrant an emergency room visit. However, some of the most serious medical emergencies – heart attack, appendicitis, ruptured abdominal aortic or cerebral aneurysm most commonly present as pain.

You’re going to need to do medical triage over your dispensing counter.

Take a look at your client. Are they walking in unassisted? Are they leaning on the counter clutching their chest? Do they look pale and sweaty? Are they limping? The physical appearance of your client could give you some idea as to just how bad the pain is.

Asking some basic questions will help you establish how serious thing are. Always ask:

•  Where is the pain? Pain in the chest, abdomen, back or head is more likely to be linked to a life-threatening emergency than pain in the toes, knees or ankles.

•  Where did the pain start? Where is it now? Chest pain associated with a heart attack typically starts in the mid or left chest and spreads down the left arm or up into the neck. Chest pain from heartburn tends to start just above the belly button and spread upwards. Back pain associated with a slipped disc often causes sharp shooting pain which travels over the buttocks and back of the legs. Similarly appendicitis pain usually starts over the belly button and then spreads to the right lower abdomen. Abdominal pain which starts in one area and then becomes very severe and spreads throughout the abdomen is sign that rupture of bowel may have occurred.

•  Is the pain acute or chronic? If the pain started in the last few hours or days it’s more likely to be linked to a serious underlying condition. This doesn’t mean that clients with chronic pain do not have a potentially serious condition.

•  How bad is the pain? The easiest way to establish this is to ask the client to give you a number on a sliding scale of 1 to 10 (1 being a minor pain; 10 being the most excruciating and agonizing pain they can imagine). It’s difficult to gauge pain as different people experience it in different ways. If it’s above a 7 or 8, you should be concerned.

•  Is the pain worsening or getting better? What helps or worsens the pain? When is the pain at its worst? Chest pain which worsens on exercise and improves at rest is usually related to angina and should be considered serious. Chest pain which worsens when coughing or breathing in usually indicates an inflammation of the lining of the lungs or inflammation of the rib muscles. Chest pain which worsens on lying down and improves on sitting up usually is indicates heartburn.

•  What kind of pain is it? Pain can be burning, throbbing, stabbing, cramping or pressing. Sharp pain versus a dull ache could distinguish between a cerebral aneurysm versus a tension headache.

•  Have they had this pain before? Clients with chronic arthritis, menstrual cramps, chronic back pain, migraines, chronic tension headaches, irritable bowel syndrome, gout attacks, gastro-oesophageal reflux disease (GORD), cystitis and other recurring conditions can often tell you that they’ve had these exact symptoms before. They usually will also be able to tell you what worked or didn’t work the last time.

•  Is there anything which triggered the pain? You could miss something very obvious like a sports-related injury, a strain injury, a motor vehicle accident, a bout of drinking or a recent upper respiratory tract infection which brought on the pain.

What other symptoms is your client experiencing?

You need to specifically ask about other possible symptoms. Clients don’t always think to tell you about these issues.

•  Nausea/ vomiting: Bowel obstruction, GORD  and appendicitis all commonly cause nausea and vomiting. A headache associated with nausea could indicate a migraine. It is also a sign of seriously raised intracranial pressure so do be concerned if you see this combination.

•  Diarrhoea: Gastroenteritis and irritable bowel syndrome both give stomach cramps and diarrhoea.

•  Severe constipation: Simple constipation can cause cramping abdominal pain. When a client can’t pass wind in addition to being constipated and having severe abdominal pain your alarm bells should be ringing – they may have bowel obstruction.

•  Fever: A client with headache and fever should raise suspicions of a possible meningitis; similarly a client with diarrhoea and fever most likely has gastroenteritis.

•  Coughing: If a client complains of chest pain along with coughing it’s entirely possible that a lower respiratory tract infection is causing the chest pain. Severe coughing can also lead to vomiting and abdominal pain.

•  Bleeding: Blood in the faeces, vomit or open bleeding from a wound all need urgent medical attention.

•  Blurred vision/ loss of vision: A headache associated with disrupted vision can be a migraine or it can be a brain tumour or a stroke. Let the casualty figure this out.

•  Numbness/ tingling: Clients don’t always know how to describe a loss of sensation. Some will tell you an area feels “numb” while others will say it feels “tingly” or like they’re “wearing thick socks”. Numbness is a sign that something in the neurological pathway is disrupted. Refer anyone with pain and numbness.

•  Rash: Shingles in particular causes severe pain, often mistaken for a muscular injury. The pain starts first followed within a few days by a patchy breakout of small fluid-filled vesicles over the affected area.

•  Urinary symptoms: Pain in the abdomen associated with burning on passing urine could indicate a bladder infection or kidney stones. Abdominal pain with the inability to pass urine usually indicates a bladder obstruction (in elderly men, normally a prostate problem).

Managing non-emergency pain

Recommending the right pain reliever to your client depends on their diagnosis, age, other medications they are taking and personal preferences.

A “one size fits all” approach won’t work. Giving an anti-inflammatory to someone with GORD will make their condition worse, whereas it will relieve chest pain caused by intercostals muscle spasm or pleuritis (inflammation of the lung lining post infection).

Non-medical management

RICE is the mnemonic to remember in any soft tissue injury which walks into your dispensary: Rest, Ice, Compression, Elevate. The majority of soft tissue bumps, strains and sprains will respond to these simple measures.

Over-the-counter medications:

Antispasmodics: For abdominal cramps you can offer your clients hyoscine butylbromide (Buscopan^®), mebeverine (Bevispas^®), propantheline (Pro-banthine^®), methixene (Spasmo-Canulose^®) and dimethicone (Telament^®)

Paracetamol: For mild pain and fever in adults and children, paracetamol is one of your safest options. There are multiple different brands available in syrups, tablets, suppositories and capsules including, Adco-paracetamol^®, Antalgic caps^®, Austell paracetamol^®, Calpol^®, Empaped^®, and many others.

Muscle relaxants: OTC muscle relaxants can help clients with neck, back and other muscle spasm. They can be used alone or in combination with anti-inflammatories and analgesics. Your options include orphenadrine (Norflex^®), methocarbamol (Robaxin^®) and mephenesin-paracetamol (Spasmend^®). Muscle relaxants should only be used in adults.

Anti-inflammatories: Non-steroidal anti-inflammatories (NSAIDs) can be given over-the-counter for a few days for acute muscular pain, menstrual pain and gout. COX2 anti-inflammatories and ongoing use NSAIDs should be prescribed by a doctor due to the possibility of side effects. Options include diclofenac drops, suppositories and tablets (i.e. Panamor^®), indomethacin (i.e. Athrexin^®); ibuprofen (i.e. Brufen^®), mefenamic acid (i.e. Ponac^®) and naproxen (i.e. Napflam^®). Keep in mind that topical anti-inflammatory patches and gels a can also help clients with localized pain.

Combination analgesics:

•  Combinations of paracetamol, codeine and caffeine include i.e. Adco-dol^®. These are some of the strongest over-the-counter medications available. Clients should only use these for short-term pain relief.

•  Combinations of paracetamol and codeine such as Adco-Napacod^®, Empacod^® and Painamol Plus^® are useful for clients with severe pain and where sensitive to caffeine.

•  Combinations of paracetamol, codeine and antihistamine such as Medipyn^® and Painagon^® are useful for severe sinus-related headaches. These meds will make your client very drowsy.

•  Combinations of paracetamol, aspirin and caffeine such as Compral^® and Excedrin^® are useful in tension headaches. Do not allow use in children under 12.

•  Combinations of anti-inflammatories and paracetamol such as Ibumol, Ibupain, Lotem^® and Mypaid^® simply make it more convenient for your clients to access combination pain relief.

These are by no means the only medications you will be offering to your client for pain relief. If the source of the pain is GORD, for example, do offer your client and H2-receptor blocker like cimetidine or ranitidine.

Advice to your client

Ongoing pain is not normal. If you have a frequent client who seems to be using over-the-counter painkillers on a regular basis, do advise them to seek medical help.

It is essential to calm the patient and to assure him/her that you can help. Always wash your hands thoroughly.

• Stop the bleeding
  • Minor cuts and scrapes usually stop bleeding on their own.
  • Most other wounds respond to gentle direct pressure with a clean cloth or bandage.  Apply gentle pressure with a clean cloth or bandage. Hold the pressure continuously for 10 to 20 minutes and if possible elevate the wound.
  • Do not keep checking to see if the bleeding has stopped because this may damage or dislodge the clot that has formed and cause bleeding to resume. If the cloth gets soak with blood, just add another on top.
  • If the continued pressure fails to stop the bleeding or if bleeding is rapid, seek medical assistance.
• Clean the wound
  • Rinse out the wound with clear water. Soap can irritate the wound, so try to keep it out of the actual wound. Do not scrub the wound.
  • Remove any dirt particles from the area and let the water from the faucet run over it for several minutes. A dirty cut or scrape that is not thoroughly cleaned can cause infection and scarring.
  • If dirt or debris remains in the wound after washing, use tweezers cleaned with alcohol to remove the particles.
  • Do not dig into the wound as this may push bacteria deeper into the wound. If debris still remains, see the doctor.
• Apply an antiseptic lotion or cream

After cleaning the wound, apply a thin layer of an antibiotic cream or ointment such as Betadine to help keep the surface moist. The products do not make the wound heal faster, but they can discourage infection and help the body’s natural healing process.

• Cover the wound
• Bandages can help keep the wound clean and keep harmful bacteria out.
• Cover the area with a bandage (such as gauze or a Band-Aid) to help prevent infection and dirt from getting in the wound.
  • Change the dressing
    • Check the area each day and keep it clean and dry.
    • Change the dressing at least daily or whenever it becomes wet or dirty. After the wound has healed enough to make infection unlikely, exposure to the air will speed wound healing.
• Get stitches for deep wounds
  • A wound that is more than 6 mm deep or is gaping or jagged-edged and has fat or muscle protruding usually requires stitches.
  • Adhesive strips or butterfly tape may hold a minor cut together, but if the wound cannot easily be held together, see the doctor as soon as possible. Proper closure within a few hours reduces the risk of infection.
• Watch for signs of infection

See the doctor if the wound is not healing or if any redness, increasing pain, drainage, warmth or swelling occurs.

• Get a tetanus shot

Doctors recommend a tetanus shot every 10 years. If the wound is deep or dirty and the last shot was more than five years ago, the doctor may recommend a tetanus shot booster. Get the booster as soon as possible after the injury.

When to see a doctor

• Heavy bleeding heavily that does not stop after five to ten minutes of direct pressure
• Wounds deeper or longer than 5 – 6 mm
• Located close to the eye
• Gaping or  ragged, separated wound margins
• Large cuts on the face
• A puncture wound

• Some punctures can be very deep and do not usually bleed much, however treatment is necessary to prevent infection. Bacteria and debris are forced deep into the tissue and the wound closes quickly forming an ideal place for bacteria to grow.

• Caused by a dirty or rusty object
• Embedded with debris such as dirt, stones, or gravel
• Caused by an animal or human bite
• Excessively painful
• Showing signs of infection such as increased warmth, redness, swelling, or drainage
  

What are the signs of a wound infection?

If the wound begins to drain yellow or greenish fluid (pus) or if the skin around the wound becomes red, warm, swollen or increasingly painful; a wound infection may be present and medical care should be sought.

Any red streaking of the skin around the wound may indicate an infection in the system that drains fluid from the tissues, called the lymph system. This infection (lymphangitis) can be serious, especially if it is accompanied by a fever. Prompt medical care should be sought if streaking redness from a wound is noticed.

At a glance

• Washing a cut or scrape with soap and water and keeping it clean and dry is all that is required to care for most wounds.
• Apply antibiotic ointment and keep the wound covered.
• Seek medical care within six hours if stitches are required. Any delay can increase the rate of wound infection.
• Any puncture wound has a high risk of infection and should be seen by the healthcare professional.
• Any redness, swelling, increased pain, fever or pus draining from the wound may indicate an infection that requires professional care.

Causes of diabetic ulceration: the following factors are closely linked to each other and play a large role in the formation of diabetic ulcers:

• Neuropathy: diabetes targets the neurological system resulting in limited or no sensation in the extremities, especially the feet. The compromised diabetic would not be able to feel any pain or discomfort often leading to tissue breakdown. Unnoticed excessive heat or cold or pressure from a poorly fitting shoe may cause blistering and ulceration.
• Trauma: any trauma to the foot may cause a wound in an already compromised area. This may result from direct trauma to the area, or indirectly, such as inadvertently leaving a blunt object in the shoe.
• Vascular complications: diabetics are at a higher risk of arterial disease which causes a narrowing of the vessels preventing blood flow to the extremities. Should a wound develop, the compromised vascular system is unable to restore complete healing to the area and this often precipitates ulceration and gangrene.
• Deformity: diabetics are prone to the formation of a Charcot foot. This deformed foot structure is caused by neurological and vascular changes within the foot.  The foot appears convex in shape, with a rocker bottom appearance. The Charcot foot is prone to producing pressure points which often become the sites of small ulcers. Charcot changes can also affect the ankle joint resulting in displacement and further ulceration.
• Callous formation: excessive pressure on joints of the feet often goes un-noticed and this may lead to callous formation and eventually ulcer formation.
• Oedema: usually a complication of hypertension; this build up of fluid around the ankle and feet may result in ulceration.
• Infection: even the smallest wound, should it become infected can create a large ulcer and eventually gangrene due to a compromised blood supply to the foot and the fact that diabetics are often immuno-compromised.

Signs and Symptoms: the following signs and symptoms are often visible and should be noted in people living with diabetes:

• Open lesion on the plantar surfaces of the foot and on pressure points
• Unnoticed injuries to the foot and leg
• Callous formation
• Blood in the socks or shoes
• Foul odour of the wound
• Discolouration of the ulcer
• Black tissue within wound
• Loss of sensation to the feet or hands
• Colour changes of the foot
• Pain or burning sensation at night

Treatment

The success of treatment of a diabetic ulcer depends on early management of the wound and compliance of the patient. Importance must be placed on the sufferer’s blood sugar control. The primary goal in treating these ulcers is to obtain complete wound closure and this is best achieved by implementing a multidisciplinary approach. A person suffering from a diabetic ulcer should be consulting with a variety of specialists. This approach has been found to reduce morbidity rates and the incidence of amputation.

The following advice can help add value to your customer:

• Relieve pressure to the area
• Footwear: good footwear is essential to the diabetic. Ill fitting shoes can cause irrevocable harm. The shoe should enclose the whole foot to prevent trauma to the area. Shoes should be flexible, light and protective.
• Patient education: educating the diabetic sufferer on the disease, its complications and the importance of compliance, can result in a successful outcome and may prevent further ulceration in the future
• Diet:  avoid foods that are high in complex carbohydrates, polysaturated fats and sugar.
• Exercise: exercise plays a large role in reducing arterial disease and should be encouraged within the sufferer’s means and abilities.
• Regular screenings and check- ups should be encouraged.

The following dressings and medicaments can add value to your customer:

• Askina ® Calgitrol ® is a foam dressing indicated for infected diabetic pressure ulcers. It combines the effectiveness of silver with the absorbency capabilities of calcium alginate and silver alginate. This combination allows exudates to be ‘withdrawn’ from the wound whilst providing a moist environment which is conducive to healing. The dressing is to remain on the wound for seven days after which a new dressing can be applied. All dressings should be prescribed by a podiatrist or doctor.
• ActiForm Cool® is a hydrocolloid dressing which maintains an optimal level of moisture in the wound bed. It is an effective method of treating infected wounds. The dressings need to be changed as per a doctor’s or podiatrist’s instructions. All dressings should be prescribed by a doctor or podiatrist.
• Oral antibiotics should be prescribed by a physician and are vital in the treatment of severely infected ulcers.

When to refer: If your diabetic client complains of ulceration of the lower limb and is not seeing any medical professional, one should advise him/her to do so immediately. Your client should have access to general practitioners, endocrinologists/diabetic specialists, podiatrists, dieticians and vascular surgeons. These practitioners work together to form a multidisciplinary team focused on wound closure and the prevention of amputation.

Conclusion: Successful treatment of diabetic ulcers depends on the sufferer’s willingness to adhere to strict guidelines set by his/her medical practitioners. Without this compliance, even the best treatment may fail. Loss of a limb is a significant risk in ulcer sufferers particularly  if treatment has been delayed. Thus educating your clients about diabetes, its risks and its complications, plays an important role in treating ulcer sufferers.

The human foot has been described as an engineering miracle bearing in mind that this relatively small area with the mechanics of 26 separate moving parts (bones) supports and translocates the human body in its full and extremely varied range of movements. For many centuries it has been known that the human foot can be a valuable diagnostic ‘tool’ and will warn an experienced practitioner that there is something awry in the body. Reflexology as an alternative healthcare practice is gaining much acceptance in all communities. The human foot is likened to a map of the body with points that correspond to all systems and will illustrate a problem to a reflexologist.

For the purposes of this article we will concentrate on general foot care and the practice of preventing problems. Most of what we discuss is common sense but bears mentioning as you will be in a position to emphasize these aspects with your clients in the pharmacy.

Good habits:

Advise your clients to consider the circulation of their feet at all times and not to impair this for a lengthy period for instance not to sit cross-legged for too long.  Sitting or standing still for too long can cause pooling; hence people should be encouraged to walk to improve circulation to the extremities. Of course, those clients who smoke must be made aware that they are seriously impeding the circulation to their feet and should quit smoking immediately. For those clients who are necessitated to stand for long periods of time e.g. hairdressers, they should try to lie down with their legs and feet elevated for a while after work (care must be taken not to occlude the popliteal vein behind the knee as this can increase the possibility of DVTs (deep venous thrombosis). A warm foot bath or a gentle massage will not only feel very relaxing but will also improve circulation.

All adults should check their feet regularly and those who are unable to do so (the elderly or infirm), should seek help from a Primary Healthcare Nurse/Practitioner or a podiatrist. It is extremely important to stress that prevention is better than cure and that so many foot problems could be prevented by practicing good foot hygiene. One should examine the feet regularly for the appearance of warts, corns or callouses, excessive dryness, scaling or any other changes.

It stands to reason that the foot is a very hospitable area for organisms to multiply, therefore special care must be taken after a bath to make sure that the feet are well dried and in most cases well moisturized. Moisturizer must be well absorbed and not applied to the area between the toes. This area must be well dried especially should the suspicion of a fungal infection exist. (Please refer to Front Shop June 2011 edition page 16 for the latest information on how to treat Athlete’s foot).

Today a plethora of foot care products is offered in most pharmacies. Your client should be able to find something that suits his/her preferences and pocket. The older exclusive foot care names like Dr Scholl’s™ and Eulactol™ have expanded their range to satisfy all needs. The skin softening creams mostly contain lactic and salicylic acid which can penetrate the hardened skin and allow the underlying skin to absorb the applied moisture. Dr Scholl’s has an extended range of plasters and cushions to prevent corns and callouses and to treat them once they have appeared. The ‘air pillo’ and gel half soles will relieve the pressure off painful areas.

Green Cross™ is a trade name that is intricately connected to comfort in shoes, hence it is no surprise that they have expanded into a more comprehensive foot care offering with creams and balms to pamper the feet.

Dr Sole™, available at Clicks markets, a complete care range as well with rough skin removers, anti-fungal foot cream, heel balm and a deep moisturizer.

Eucerin® Foot Cream, (with 10% urea to penetrate dry layers) is particularly useful in the winter when one tends to be so dry.

Initially when Pedi-Relax appeared on the SA market, it was only available in a foot moisturizer that specifically targeted the needs of diabetic patients. They too have expanded their range and now offer products that cater for a variety of needs. There are products that address common foot conditions like dryness and perspiration and the more specialized needs of sports people.

Pharmacy chains like Dis-Chem and Clicks have complete foot care in-house ranges with exfoliators, creams, masks and scrubbing brushes to suit every need. These ‘kits’ very often include nail clippers that your customers can use to trim their toe nails. Please remind them that this should be done straight across the toenail and be quite short.

For those who wish to use home-remedies, a teaspoon of sugar in a tablespoon of olive/almond/grape seed oil, massaged into the feet will not only render a very relaxing sensation but will act as an excellent exfoliater and moisturizer as well. To improve absorption of a moisturizer significantly, wrap the feet in ‘cling wrap’ overnight. This makes a huge difference. (Best your client does this when his/her spouse is out of town for the night, plastic coated feet are a definite passion killer!)

Please advise your clients to wear socks that do not constrict around the ankle area and to preferably choose natural fibre socks (especially if they or their family are in a high-risk group e.g. diabetics).

Selecting foot ware

The mega-pharmacy is a phenomenon that is taking off in SA. Today most of a family’s shopping can be done at the local Dis-Chem or Clicks. This places a huge responsibility on you, the pharmacist assistant or the pharmacy assistant and you may very well find yourself having to advise a customer purchasing Green Cross or FitFlop™ shoes. Please keep these simple guidelines to hand so that your customer will leave your establishment with the best-fitting shoes (and you can be proud that you have offered a professional service which is not often enjoyed by the SA consumer)

• Due to the fact that one’s feet change in shape and size with age, make sure you measure your customer’s feet. Do not encourage people to select shoes based on the size only, but, rather on how a particular shoe fits.
• Advise your client to leave their shoe shopping until the end of the day (the feet are slightly larger at the end of a day’s activity)
• Measure and fit both feet, the size and shape of one’s feet can vary. Shoes must accommodate the larger of the two feet so as not to cause trauma to the other foot.
• Encourage the client to select a shoe that more-or-less has the same shape as his/her foot.
• Make sure that there is enough space to accommodate the longest toe in the front of the shoe (at least 1 – 2 cm) when standing (this is most important). Never advise a client to purchase shoes that will ‘be comfortable once they have stretched’
• The ball of the foot must fit the widest part of the shoe and the shoe must not ride up and down the heel whilst walking (this will chafe the skin and cause trauma to the foot)
• Soles should be solid and slip-free.
• Leather is the best material to prevent any skin irritation

Chronic foot pain is quite a common complaint today and not only seen in the elderly or those who are on their feet all day. This can be due to an injury or a disease therefore, when such a client presents, a detailed history should be recorded. If the pain is due to ligament sprains, muscle strains, bruising or fractures, the client should be referred to a medical practitioner for evaluation.  The Smith and Nephew range of orthopaedic products will assist in stabilizing and immobilizing a strain or sprain and allow the ligaments and muscles to heal. Should the client experience chronic arch pain, it could be that the plantar fascia has been injured (this is the tough fibrous sheath that runs the length of the foot and supports the arch). This is where all the shock absorption of the foot takes place. This inflammatory process can be extremely painful and referral to a podiatrist is essential.

There are two very important high-risk groups regarding foot care namely those living with diabetes and the elderly. As a member of the healthcare team, with whom the consumer has a trusting relationship, it is incumbent on you to encourage these groups to take extreme care of their feet and thereby prevent any problems. An elderly client should see your nurse colleague in the primary healthcare clinic or a podiatrist.

You can use the following as guideline when discussing foot care with a diabetic client, if your client experiences any of the following, they should consult their diabetologist and podiatrist post haste:

• Numbness in the feet
• Burning sensation of the feet
• Tingling sensation of the feet
• Inadvertent, repetitive injuring of the feet
• Any infection such as dermatitis, Athlete’s foot
• Continuous itching of the feet

Conclusion: Let’s all put our best foot forward and remember to encourage all your clients to pamper these often undervalued parts of their bodies.

The urinary system consists of the kidneys, ureters, bladder and the urethra. The key elements in the system are the kidneys, which remove excess liquid and waste products from the blood and produce urine. Narrow tubes called ureters carry urine from the kidneys to the bladder where it is stored until emptied through the urethra.

Causes

Normally, urine is sterile. It is usually free of bacteria, viruses and fungi but does contain water, salts and waste products. An infection occurs when tiny organisms, usually bacteria from the digestive tract, cling to the opening of the urethra and begin to multiply. The urethra carries urine from the bladder to outside the body. Most infections arise from Escherichia coli (E. coli), which lives in the colon.

Some people are more prone to contracting a UTI than others, especially if the bladder is not voided completely when visiting the toilet. Any abnormality of the urinary tract that obstructs the flow of urine (a kidney stone, for example) can cause an infection. An enlarged prostate gland can also slow the flow of urine, thus raising the risk of infection. Catheters or tubes placed in the urethra and bladder can cause an infection.

People with diabetes have a higher risk of infection because of changes in the immune system. All disorders that suppress the immune system may increase the risk of a urinary infection. Many women suffer from recurrent infections and it is estimated that 20% of women who have one UTI, are likely to have another, and a further 30% of those will have yet another. Almost like a vicious cycle, with the causative strain bacteria always being slightly different to the previous infection. Due to the prevalence of these infections, extended research is being done to curb and of course, cure UTIs.

It has been found that a UTI in a pregnant woman tends to travel to the kidneys, which makes it more serious, and for this reason, many doctors recommend routine testing of urine during pregnancy.

Symptoms

Strangely enough, not everyone with a UTI has symptoms. The most common symptoms experienced are:

-       A frequent urge to urinate.

-       Painful, burning feeling in the bladder or urethra during urination.

-       A general feeling of malaise, fatigue, shakiness and a washed out feeling.

-       Pain, even when not urinating.

-       Women often experience an uncomfortable pressure above the pubic bone.

-       The urge to urinate is huge, but the amount of urine passed is small.

-       Urine may appear milky or cloudy.

-       If fever is present it could indicate that the infection has reached the kidneys.

-       A kidney infection could present with back pain, pain below the ribs, nausea and even vomiting.

To diagnose a UTI, the doctor will test a midstream urine sample. This sample can be sent to a laboratory, but some doctors’ rooms are equipped to do the testing immediately.

Another good reason for going to the doctor with this type of infection is that it could be more serious, such as involving an infection of the kidneys or even possibly kidney stones, especially if the infection recurs regularly.

Treatment

Urinary tract infections are treated with antibacterial drugs. The actual drug and time of treatment will depend on the patient’s history and the results of the urine test that identifies the offending bacteria. Most antibiotics prescribed for uncomplicated UTIs are the quinolones which have been approved for treating these infections. It is important to ensure that patient’s are counselled to take the full course of treatment because symptoms may disappear before the infection is fully cleared, resulting in resistance.

Other steps that can be taken by the patient to prevent recurrence:

-       Drink plenty of water every day.

-       Urinate when the need is felt, don’t wait till it is almost too late.

-       Wipe from front to back when going to the toilet.

-       Take showers instead of bathing.

-       Do not use feminine sprays and scented douches.

Home Remedies and Treatment

For a mild infection, treatment at home or with over- the -counter medication could resolve the problem:

-       A popular remedy is to take copious amount of liquid, such as fresh fruit juice and water.

-       Citro Soda^® taken every few hours as well as a lot of water to help alkalinise the urine.

-       Taking a mixture of bicarbonate of soda in water can also be helpful, and has a similar effect  as Citro Soda^®

-       Drink lots of unsweetened cranberry juice, fresh juice is even better.

-       Vitamin C is said to prevent bacterial growth due to the acidic environment created in the bladder and urinary tract.

-       Maintain the alkaline content in urine by a rich diet of milk, fruits and fresh vegetables.

-       Avoid artificial sweeteners, such as aspartame as they could aggravate a bladder infection.

It is not always possible to prevent a urinary tract infection, but if treated as soon as the first symptoms are noticed, it could shorten the treatment period and resolve symptoms faster. For those lucky women who have never suffered from this type of infection, count yourself extremely fortunate. For those women who have suffered the debilitating symptoms of a UTI they will recognise the symptoms immediately. It is like toothache, best avoided if at all possible.

During vomiting the diaphragm contracts downwards. At the same time the abdominal muscles tighten against the relaxed stomach with an open gastro-oesophageal sphincter. The content of the stomach is then propelled up and out. The body produces more saliva just before vomiting as part of the vomiting reflex.  Vomiting is a complex reflex coordinated by the vomiting centre of the brain. There is a wide range of stimuli that trigger vomiting from food poisoning to migraines to kidney stones. Sometimes just seeing someone else vomit will start a vomiting reflex.  It responds to various stimuli including:

• from the mouth, stomach and intestines,
• the bloodstream which may contain medicine of infections.
• balancing systems in the ear as in motion sickness
• the brain itself including unnerving sights, smells or thoughts.

Causes of nausea and vomiting

Nausea and vomiting is a symptom of many conditions. Causes of vomiting are summarised in table 1.

Table 1 the possible causes of vomiting

The causes of vomiting differ according to age. For children, it is common to vomit from viral infections, food poisoning, milk allergy, motion sickness, over eating or feeding, coughing or blocked intestines and illness in which the child has a high fever.

The timing of the nausea and vomiting can indicate the cause. When it starts shortly after a meal in may be as a result of food poisoning, gastritis, an ulcer or bulimia. Nausea or vomiting one to eight hours after a meal may also be as a result of food poisoning. Certain food borne bacteria, such as salmonella can take longer to produce symptoms.

Treatment of nausea and vomiting

Most of the time nausea and vomiting are harmless and do not require urgent medical attention. However it can be a sign of more serious illness such as concussions, intestinal blockages, appendicitis and meningitis or brain tumour. If the symptoms continue for more than one day, are severe and  food and fluids cannot be kept down for any length of time, there is blood in the vomit, severe abdominal pain, a fever over 38°C or diarrhoea, rapid breathing and pulse,  immediate treatment needs to be initiated.

Dehydration is the main concern with most vomiting. Adults have a lower risk of becoming dehydrated because they can usually detect the symptoms of dehydration (such as increased thirst and dry lips or mouth). But, children have a greater risk of becoming dehydrated, especially if they also have diarrhoea, because young children are often unable to communicate symptoms of dehydration. Adults caring for sick children need to be aware of these visible signs of dehydration: dry lips and mouth, sunken eyes, and rapid breathing or pulse. In infants, also watch for decreased urination and a sunken fontanelle (soft spot on top of the baby’s head).

Recurrent vomiting in pregnancy can lead to a serious condition called hyperemesis gravidarum where the mother may develop fluid and mineral imbalances that can endanger her life or that of her unborn

Treatment for vomiting (regardless of age or cause) includes:

1. Recognise and correct the dehydration and electrolyte imbalance.

• Drinking gradually larger amounts of clear liquids.
• Avoiding solid food until the vomiting episode has passed.
• On advice of the healthcare provider temporarily discontinue all oral medications (which can irritate the stomach and make vomiting worse).
• If vomiting and diarrhoea last more than 24 hours, an oral rehydrating solution such as Rehydrate® should be used to prevent and treat dehydration.
• Those with significant dehydration or electrolyte abnormalities and those who cannot tolerate liquids by mouth usually require intravenous fluids.

1. Try to identify the underlying cause of the nausea and vomiting and that should be treated.
   1. If no specific cause can be identified OTC medications for nausea and vomiting include cyclizine (Valoid® or Adco-Cyclizine®) or buclizine (Vomifene®). These are antihistamines which block the messages going to the vomiting centre in the brain. These work well if they are taken before the symptoms appear e.g. as a prevention of motion sickness.  Ensure that patients are not taking any other antihistamines in cold and flu medication or pain killers and anti-allergy medication to avoid overdosing. There is various prescription anti-emetics that are indicated for post-operative nausea and vomiting and that associated with cancer treatments. Emetrol ®or Emex® which are sucrose and phosphoric acid combinations can also be administered for nausea in motion sickness and early pregnancy.

Prevention of nausea

There are several ways to try and prevent nausea from developing. Nausea and vomiting as a result of motion sickness can be avoided by the patient sitting so that they look out of the front windshield. Watching fast movement out of the side windows can make the nausea worse.  Advise that the patients do not eat and work/play at the same time. The food should settle in the stomach before activity is started. Patients should drink small amounts of clear liquids frequently. Eat small meals throughout the day instead of three large meals. Eat slowly. Avoid ‘hard to digest’ foods. Consume foods that are cold or room temperature to avoid the nausea from the smell of hot or warm foods. Eat when they are feeling less nauseated.

Conclusion

Nausea and vomiting are common symptoms of an underlying disorder. The dehydration as a result of vomiting is the concern that should be addressed first in the treatment. A doctor should be consulted if the vomiting is severe and the cause cannot easily be identified.